HomeMy WebLinkAbout935 Wells Ave Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 08/15/12 Receipt#: 141135
Transaction(s): Reference Subtotal
1 1 Excavation Permits 784 $200.00
Check#: 23173 Total Paid: $200.00
Name: National, Grid -Gas Constr. Dept
175 E Old Country Rd
Hicksville, NY 11801
Clerk ID: LINDAC Internal ID:784
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Permit No. TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
File No. Peconic Lane
RECE'V D
Peconic,New York 11958
(631)765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR AUG 1 5 201?
Ref#T1013IsniK373001d Town Clerk
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold,Suffolk County,New York,and other
applicable laws,ordinances or regulations for the excavation herein described. The applicant agrees to comply with all
applicable laws,ordinances,codes and regulations,and to permit authorized inspectors to make necessary inspections of the
job site.
Print or Tvpe
1NATIONAL GRID–GAS OPERATIONS DEPT.–
111801 175 E.OLD COUNTRY RD.–HICKSVILLE NY
Name of Applicant
Address
2 935 Wells Ave. Southold
Owner of Premises Address
3) Opening a 4'x 6' bellhole and a 100'x1' trench on the W/s of Wells Ave. a rox. 50' n/o Harper
Rd.W.to install a as main and service.
4) Work Description and Location(Street Number,Hamlet,Cross Street)
(a) Is construction located within 75 feet of tidal wetlands? *Yes
*If yes,other Town permits may be required. No—X
4) Builder's License No.
Plumber's License No.
Electrician's License No. Other Trade's License No.
Signature of Applicant'—'-
08-14-12
Dat
5) a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
Public streets or areas,and giving a detailed description of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
C) Work covered by this application may not commence before issuance of a Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section Block
Lot
7) Starting Date:
Completion Date:
8) Work Schedule:
Phase
Excavation ......................................................................... Completion Date
Facility Installation........................
Backfill&Comt;action.........................................................
Pavement Replacement.........................................................
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D-39
12) Insurance Covera�c: (Attach Copy)
a) Insurance Company: _-
b) Policy#_
c) State whether policy of certification on file with the Highway Department
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,and$50,000 property damage.
13) Security:
a) Surety Bond or Certified Check provided in the total amount
of$
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee $150.00
Al. /Service Connections excavations(a)$20.00= +20.00 bellhole+30.00 for
trench fee 100'trench fee
And ca. foot from '
A trench=$200.00
A2. /Additional Excavations same service(u$10.00
No.
B. Excavations 18" in depth or less:
0-100 I.f=$10.00-
1.f. (a)$0.10=
Additional
C. I?xcavations 18"in depth to 5' in depth:
0-100 Lf. _
Additional If(a).30 - of trench 100'
D. Excavations 5' in depth and over:
0-1001.f. $50.00
$30.00 If (a)$0.50=$
Additional
E. Utility Repair Excavations(a%$10.00=S
No.
Repairs same service(i $5.00=S
Additional
F. Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST= $200.00
�tiUthlirlLUtWii is hereby granted to the Town Clerk of clic ;own of SUutllUid to issue a I iighway I:1xC8VaUOn Permit tu:
NATIONAL GRID in accordance with this application.
SUP TENDENTOFHIGHWAYS
T WN O SOUFHOLD, W YORK
- -
Pctc�r(W. Harris
3- - JJ
_ Date
Received by the Town Clerk
Date
Permit Issued �' �5��L+- Permit No.-
Note:
o Note: Permit expires one(I)year from Date of Issuance. No work to start without 48 hour notice to the Superintendent of Highways.
Permit Hurst be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date Findings(use code) Applicant Notified
I st
,d -
3`1
4th
(To Permit Clerk)
REMARKS
CODE
IB- Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure(due to backfilling)
BUC - Building under Construction
WIP - Work in Progress
DB - Improper backfill(too high) (not sufficient)
HFS - Inspector holding for final settlement of excavation
RFR- Ready to Repair
D_;y Page 3 of 3
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